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Received: 2 August 2018    Revised: 21 February 2019    Accepted: 28 March 2019

DOI: 10.1111/clr.13435

ORIGINAL ARTICLE

The accuracy of static vs. dynamic computer‐assisted implant

surgery in single tooth space: A randomized controlled trial

Dechawat Kaewsiri1 | Soontra Panmekiate2 | Keskanya Subbalekha1  |

3,1 1
Nikos Mattheos  | Atiphan Pimkhaokham

1
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Chulalongkorn Abstract
University, Bangkok, Thailand Objectives: The aim of this RCT was to compare the accuracy of implant placement
2
Department of Radiology, Faculty of
between static and dynamic computer‐assisted implant surgery (CAIS) systems in sin‐
Dentistry, Chulalongkorn University,
Bangkok, Thailand gle tooth space.
Materials and methods: A total of 60 patients in need of a single implant were ran‐
3
Implant Dentistry, Faculty of Dentistry, The
University of Hong Kong, Hong Kong SAR,
China
domly assigned to two CAIS groups (Static n = 30, Dynamic n = 30) and implants
were placed by one surgeon. Preoperative CBCT was transferred to implant planning
Correspondence
Atiphan Pimkhaokham, Department of
software to plan the optimal implant position. Implants were placed using either ste‐
Oral and Maxillofacial Surgery, Faculty of reolithographic guide template (Static CAIS) or implant navigation system (Dynamic
Dentistry, Chulalongkorn University, 34
Henri Dunant Road, Wangmai, Patumwan,
CAIS). Postoperative CBCT was imported to implant planning software, and deviation
Bangkok, 10330 Thailand. analysis with the planned position was performed. Primary outcomes were the de‐
Email: atiphan.p@chula.ac.th
viation measurements at implant platform, apex, and angle of placement. Secondary
Funding information outcome was the distribution of the implant deviation into each 3D direction.
90th Anniversary of Chulalongkorn
University Rachadapisek Sompote Fund.;
Results: The mean deviation at implant platform and implant apex in the static CAIS
Chulalongkorn University group was 0.97 ± 0.44 mm and 1.28 ± 0.46 mm, while that in the dynamic CAIS group
was 1.05 ± 0.44 mm and 1.29 ± 0.50 mm, respectively. The angular deviation in static
and dynamic CAIS group was 2.84 ± 1.71 degrees and 3.06 ± 1.37 degrees. None of
the above differences between the two groups reached statistical significance. The
deviation of implants toward the mesial direction in dynamic CAIS group was signifi‐
cantly higher than that of the static CAIS (p = 0.032).
Conclusions: Implant placement accuracy in single tooth space using dynamic
CAIS appear to be the same to that of static CAIS. (Thai Clinical Trials Registry
TCTR20180826001).

KEYWORDS
accuracy, computer‐assisted surgery, dental implant, navigation, stereolithography

1 |  I NTRO D U C TI O N
Dental implant prostheses have been shown to be a very success‐
ful treatment modality for replacement of missing teeth (Jung et al.,
2008). Nevertheless, proper implant position is considered today
an essential prerequisite for ensuring successful treatment out‐
comes, as well as long‐term maintenance of the prosthesis and the
peri‐implant tissue health. Poor treatment planning and deficient
surgical procedures may lead to compromised implant position and
thus predispose to compromised outcomes and short‐ or long‐term
complications (Buser et al., 2012; Buser, Martin, & Belser, 2004).
Conventional methods for implant placement, such as freehand
placement or use of prosthetic surgical guide made on the study model,
do not provide reliable reproduction of the optimal planned implant

Clin Oral Impl Res. 2019;30:505–514. wileyonlinelibrary.com/journal/clr   © 2019 John Wiley & Sons A/S. |  505
Published by John Wiley & Sons Ltd
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506       KAEWSIRI et al.
position in the surgical site. As however digital technology expands
in the medical field, computer‐assisted implant surgery (CAIS) was in‐
troduced in 1995 (Fortin, Coudert, Champleboux, Sautot, & Lavallee,
1995) to allow for an accurate reproduction of the planned optimal im‐
plant position to the surgical site. The principle of CAIS is to utilize com‐
puted tomography (CT) combined with an implant planning software in
order to allow the simulated virtual implant placement in the optimal 3‐
dimensional position on multiplanar reconstruction images of the oral
tissues. Once the optimal 3‐dimensional position is achieved, two dif‐
ferent systems are available to assist in transferring the virtual plan to
the surgical site, either static or dynamic CAIS (Widmann & Bale, 2006).
The static CAIS system utilizes a CAD/CAM generated surgical
guide with an embedded “sleeve” which can precisely guide implant
drilling and placement. The surgical guide is placed on the neighbor‐
ing teeth and it can allow reliable transfer of the planned implant po‐
sition (Ruppin et al., 2008; Somogyi‐Ganss, Holmes, & Jokstad, 2015).
Dynamic CAIS system uses motion tracking technology to track
implant drilling instruments and patient's jaw position. Radiopaque
markers (i.e., fiducial markers) which are attached to the patient's
jaw while taken the CT scan, are used at the time of the surgery to
provide a synergistic movement between the corresponding anat‐
omy in the CT image and the surgical field. Tracking cameras are set
up during surgical procedure to continuously track sensors which
attached on the patient's jaw and the surgical handpiece, and display
them in real‐time on the monitor superimposed to the virtual plan.
Any 3‐dimensional deviation of the drill and implant from the virtual
plan can be seen in real‐time and adjustment of the drilling depth and
angle or implant position can be performed at any time.
The accuracy of transferring the virtual implant position to the
patient using static and dynamic CAIS systems has been shown to
be superior compared to conventional implant placement methods
(Block, Emery, Lank, & Ryan, 2017; Brief, Edinger, Hassfeld, & Eggers,
2005; Farley, Kennedy, McGlumphy, & Clelland, 2013; Ruppin et al.,
2008; Somogyi‐Ganss et al., 2015). However, there are limited clin‐
ical studies which systematically compare transferring accuracy be‐
tween static and dynamic CAIS systems, particularly in single tooth
space implant placement. Thus, the aim of this randomized clinical
trial was to compare the accuracy of implant placement in terms of
deviation from the digitally planed optimal position, as well as inves‐
tigate the distribution of the deviation to each 3D direction between
implants placed using static and dynamic CAIS systems in single tooth
space. The null hypothesis of the study was that the accuracy of im‐
plant placement using dynamic CAIS system in single tooth space is
not different to that deriving from the use of static CAIS system.
2 |  M ATE R I A L S A N D M E TH O DS
This study has been approved by the Human Research Ethics
Committee of the Faculty of Dentistry, Chulalongkorn University
(study code: HREC‐DCU 2017–052) and registered at the Thai Clinical
Trials Registry database (study code: TCTR20180826001). Informed
consent was acquired by all patients. The study followed the CONSORT
statements for reporting clinical trials. All surgeries were performed
at Department of Oral and Maxillofacial Surgery, Chulalongkorn
University between June 2017 and June 2018 by one surgeon.
2.1 | Power calculation
Based on the implant platform, apex, and angle deviation val‐
ues of static and dynamic CAIS systems reported in previous
studies (0.21 ± 0.16 mm vs. 1.37 ± 0.55 mm, 0.32 ± 0.34 mm vs.
1.56 ± 0.69 mm, and 1.35 ± 1.11 degrees vs. 3.62 ± 2.73 degrees,
respectively) (Behneke, Burwinkel, & Behneke, 2012; Block et al.,
2017), the minimum required sample size of 10, 14, and 48 implants
according to platform, apex, and angle deviation, respectively, was
separately calculated using a statistical software (G*Power software
version 3.1, Erdfelder, Faul, & Buchner, 1996) for Mann–Whitney U
test with 95% of study power and significant level (α) of 0.05.
2.2 | Population
Patients who required dental implant prostheses for a single tooth
missing for at least 3 months, had adequate bone volume for implant
placement (including implant placement with simultaneous bone aug‐
mentation), and older than 20 years of age were invited to participate in
this study. Patients with systemic conditions which could compromise
osseointegration and/ or healing process, limited mouth opening (inter‐
incisal range less than 40 mm)were excluded from the study. Sixty con‐
secutive patients who fulfilled the above criteria and offered consent
were enrolled in the study. Patients were randomly allocated to one of
two groups: static CAIS group (n = 30) and dynamic CAIS group (n = 30)
using block randomization method with six samples in each block.
2.3 | CBCT scan procedure
All patients received a Cone‐Beam Computed Tomography (CBCT)
scan by 3D Accuitomo 170 machine (J.Morita Inc., Kyoto, Japan). The
settings were 5 mA, 90 kV, 0.25 x 0.25x 0.25 mm voxel size, field of
view 10 x 5 cm. For dynamic CAIS group, a 1.5 mm thick vacuum‐
forming stent, connected to an occlusal device that contains 4 ra‐
diopaque fiducial markers (IRIS–100, EPED Inc.), was inserted to the
operating arch during the scan procedure and was stored for later
use as registration stent at time of surgery.
2.4 | Implant placement planning procedure
The plan of the implant placement for both static and dynamic
CAIS groups was performed by one operator different to the one
who performed the surgeries. Optimal implant positioning was
planned as described by Buser et al. (2004). DICOM format data
set of CBCT image were imported to the implant planning soft‐
ware, either coDiagnostiX software version 9.7 (Dental Wings Inc,
GmbH) for static CAIS group or Iris–100 software (EPED Inc.) for
dynamic CAIS group. A virtual implant of Straumann implant sys‐
tem (institute Straumann AG) was placed from the existing library
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designed and the planning file was sent to a certified manufactur‐

ing dental laboratory to produce a stereolithographic surgical guide
(VisiJet MP200, VisiJet M3 Stone Plast, 3D Systems, Inc.). A 5 mm
diameter Straumann T‐sleeve was embedded in the guide as per
manufacturer's instructions in order to guide the drill and implant
placement.

2.5 | Surgical implant placement

F I G U R E 1   Illustration of the parameters indicates the implant
deviations. The purple implant represents the planned virtual
implant. The gray implant represents the placed implant. The yellow
line represents the central axis of each implants
in each software, superimposed on the multiplanar reconstruction
images from CBCT scan, and aligned to the optimal 3 dimensional
position based on the restorative and biologic principles. For static
CAIS group, STL file from model scanning (D900L scanner, 3Shape)
or intraoral scanning (TRIOS, 3Shape) was also imported and merged
on DICOM image, then a 3  mm thick teeth‐supported guide was
TA B L E 1   Demographic and clinical data of patients
p–value
Static CAIS Dynamic CAIS (Chi‐square
Group (n = 30) (n = 30) test)
All surgeries were performed by one surgeon who had placed more
than 500 implants using conventional method and more than 50
implants using each static and dynamic CAIS systems. Straumann
implants diameter 3.3–4.8 mm length 8–12 mm were placed under
local anesthesia using either stereolithographic surgical guide tem‐
plate for static CAIS group or implant navigation system machine
(IRIS‐100, EPED Inc.) for dynamic CAIS group as guidance methods.
In the cases where adequate keratinized mucosa was available, a
flapless approach was applied.
2.5.1 | Static CAIS surgical protocol
Prior to surgery, the stereolithographic surgical guide template for
static CAIS group was inserted and controlled for stability. Once
stability was confirmed, implant placement was performed accord‐
ing to the guidance protocol of Straumann guided surgery system.
Implants which did not achieve insertion torque of 25 Ncm or more
were excluded from the study (Trisi et al., 2009).

Mean age (year) 57 (28–74) 50 (21–70) 0.12 2.5.2 | Dynamic CAIS surgical protocol
Gender (n)
The registration process was applied prior to surgery in the dynamic CAIS
Male 9 7 0.56
group. An infrared tracking camera was set and two tracking sensors
Female 21 23
were connected to the handpiece and the registration stent. Handpiece
Position (n) registration was performed by set the tracking camera to identify the po‐
Anterior 6 4 0.65 sition and orientation of the handpiece and the drill. Patient registration
Premolar 9 12
TA B L E 2   Implant characteristics
Molar 15 14
Left side 13 15 0.61 p–value
Static CAIS Dynamic CAIS (Chi‐square
Right side 17 15
Group (n = 30) (n = 30) test)
Maxilla 21 16 0.18
Implant type (n)
Mandible 9 14
Bone level 24 18 0.23
Bone augmentation (n)
Bone level taper 4 9
Yes 15 10 0.19
Tissue level 2 3
No 15 20
Implant diameter (n)
Surgical technique (n)
3.3 mm 5 8 0.63
Open flap 25 25 1.00
4.1 mm 13 12  
Flapless 5 5
4.8 mm 12 10  
Timing of placement (n)
Implant length (n)
Early 6 6 1.00
(≤4 months) 8 mm 7 5 0.61

Late 24 24 10 mm 21 21
(>4 months) 12 mm 2 4
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TA B L E 3   Deviations of implant
Static CAIS Dynamic CAIS p‐value (independent
position
Group (n = 30) (n = 30) two‐sample t test)

Platform deviation (mm)

Mean ± SD 0.97 ± 0.44 1.05 ± 0.44 0.47
Median 0.92 1.03
Min–Max 0.18–1.83 0.37–2.04
95% CI 0.80, 1.13 0.89, 1.21
Apex deviation (mm)
Mean ± SD 1.28 ± 0.46 1.29 ± 0.50 0.94
Median 1.28 1.25
Min–Max 0.49–2.13 0.61–2.31
95% CI 1.11, 1.45 1.10, 1.48
Angular deviation (degrees)
Mean ± SD 2.84 ± 1.71 3.06 ± 1.37 0.60
Median 2.80 2.91
Min–Max 0.20–6.60 0.43–6.54
95% CI 2.21, 3.48 2.54, 3.57

was performed by identified the fiducial markers in the surgical site to
provide a synergistic movement between the fiducial markers in CBCT
image and in the surgical field. When the registration was completed, the
fiducials containing device was removed. The position of the drill related
to the alveolar bone was now displayed on the navigation screen based
on CBCT images containing the outline of planned virtual implant. The
type of each virtual drill was selected from a database corresponding
to the active drill. Implant bed preparation and implant placement were
performed under visual guidance as provided by the navigation system.
Implants which did not achieve insertion torque of 25 Ncm or more were
excluded from the study (Trisi et al., 2009).
2.6 | Postsurgical care
All patients were given antibiotics (amoxicillin 1 g twice a day for
5 days) and analgesic drugs (mefenamic acid 500 mg 3 times a day for
5 days). Postimplant placement CBCT scan with the same settings as
previously was taken 1 week after surgery. For dynamic CAIS group,
the same registration stent and fiducials containing device were in‐
serted during the scan.
2.7 | Outcome measurement
Implant accuracy analysis was performed using coDiagnostiX software
version 9.7 (Dental Wings Inc, GmbH) for static CAIS group and Iris–
100 software (EPED Inc.) for dynamic CAIS group. Preoperative CBCT
image, which contains the virtual implant, and postoperative CBCT
image were fused in 3D environment using surface‐based registration
for static CAIS group and marker‐based registration for dynamic CAIS
group. Another virtual implant was placed intimately onto the placed
implant position on the postoperative CBCT image to make the soft‐
ware recognize the location of the placed implant. The deviation of the
placed implant related to the planned implant was automatically calcu‐
lated by the software (Figure 1). The primary outcomes were as follows:
• 3D deviation at implant platform: the linear displacement in mm
between the planned and placed implants, as measured at the
center of implant platform.
• 3D deviation at implant apex: the linear displacement in mm be‐
tween the planned and placed implants as measured at the center
of implant apex.
• Deviation of implant axis: the deviation in degrees (o) between the
planned and placed implants center axis line.
Secondary outcome was the distribution of the implant devia‐
tion to each direction in all planes (mesial‐distal, buccal‐lingual, api‐
cal‐coronal). The implants that deviated into the same direction in
each plane were group together and median value of the deviation
in each group was measured. This measurement allowed to visualize
the “vector” of the deviation.
An additional outcome was the total surgical time in cases with
and without bone augmentation procedure for both groups. Time

F I G U R E 2   Distribution of the deviation of each implants. Dots and lines represent magnitude and direction of the deviation. The triangle
markers represent median value of the deviation in millimeter of each direction (mesial, distal, buccal, lingual, apical, coronal). The number
in () represent the amount of implants that deviate in each directions. Blue color represents static CAIS group. Orange color represents
dynamic CAIS group. (a) mesio‐distal vs. bucco‐lingual deviation at implant platform. (b) mesio‐distal vs. apico‐coronal deviation at implant
platform. (c) bucco‐lingual vs. apico‐coronal deviation at implant platform. (d) mesio‐distal vs. bucco‐lingual deviation at implant apex. (e)
mesio‐distal vs. apico‐coronal deviation at implant apex. (f) bucco‐lingual vs. apico‐coronal deviation at implant apex. *Mann–Whitney U test.
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was measured from first incision until completion of suturing.
Indeed, the flapless placement could influence the total surgical time
and implants placed under such protocol were analyzed separately.
In dynamic CAIS group, the additional time for registration was re‐
corded. Clinical observation of intraoperative and postoperative
complications was also recorded.
2.8 | Statistical analysis
Measurements were imported into IBM SPSS Statistics software
version 22 (SPSS Inc.). Chi‐square test was used to compare the de‐
mographic data and implant characteristic between static CAIS and
dynamic CAIS groups. The normality of data distribution of primary
and secondary outcomes was calculated using Kolmogorov–Smirnov
test. 3D deviation at implant platform, implant apex, and angular
deviation between static CAIS and dynamic CAIS groups was com‐
pared. Platform and apex deviation of implant clusters that deviated
to mesial, distal, buccal, lingual, apical, and coronal directions of both
groups were illustrated using scattering plot and compared between
the two groups. Independent two‐sample t test was applied in case
with the data was normally distributed. Mann–Whitney U test was
applied in case with the distribution was not normal. p‐value < 0.05
was considered as statistically significant.
3 |   R E S U LT S
Sixty patients received single implants as according to the rand‐
omization into two groups. The population included 16 males and
44 females with mean age of 53 years (range 21–74). All implants
achieved 25 Ncm insertion torque or more. Most implants were
placed in posterior region (83.3%). Twenty‐five implants (41.7%)
were placed with simultaneous bone augmentation (18 implants
with Guided Bone Regeneration (GBR), 7 implants with transcr‐
estal sinus augmentation). Flapless approach was applied in 10
implants (17.2%). No patient dropped out and all anticipated meas‐
urements were conducted. There were no statistical significant
differences of sample characteristics (mean age, gender, position
of implant, GBR, flap technique, and timing of implant placement)
between the two groups (Table 1). Moreover, no significant differ‐
ence was found related to the implant type, diameter, and length
(Table 2).
Mean implant deviations at platform and apex in the static CAIS
group were 0.97 ± 0.44 mm and 1.28 ± 0.46 mm, respectively,
while that in the dynamic CAIS group was 1.05 ± 0.44 mm and
1.29 ± 0.50 mm, respectively. Angular deviation in static and dy‐
namic CAIS groups was 2.84 ± 1.71 degrees and 3.06 ± 1.37 degrees,
respectively. The data distribution was normal in all data sets of pri‐
mary outcomes; therefore, independent two‐sample t test was used
for comparison. No significant differences were found between the
two groups (Table 3). Mann–Whitney U test was also applied for
comparison, however, the results were not significant difference, so
that this analysis was not presented.
The distribution of the implant platform and apex deviation
to each direction is visualized in the scattering plots presented in
Figure 2. The data were not normally distributed, so, Mann–Whitney
U test was applied. Only the implant cluster that deviated into mesial
direction was significantly different between the two groups, with
higher deviation in the dynamic CAIS group (p = 0.032). No signif‐
icant differences were found in the platform and apex deviation in
other implant clusters between both groups.
Average surgical time of static and dynamic CAIS under flap
in cases without bone augmentation was 15 min (12–20 min) and
18 min (13–25 min), in cases with GBR were 40 min (30–45 min) and
48 min (30–90 min). When the implants were placed with a flap‐
less approach, the average surgical time was 13 min (12–14 min) and
17 min (12–22 min) for static and dynamic CAIS, respectively. In dy‐
namic CAIS group, an additional average time of 3 min (2–5 min) was
added for the registration procedure. The surgeries were well toler‐
ated by all patients. Only mild pain and swelling were observed. No
major intraoperative and postoperative complications were found.
4 | D I S CU S S I O N
The optimal 3‐dimensional implant placement is essential for sin‐
gle dental implant restorations in order to ensure appropriate de‐
sign of the prosthesis as well as proper function, esthetics, and
long‐term sustainable health of the peri‐implant tissues (Angkaew,
Serichetaphongse, Krisdapong, Dart, & Pimkhaokham, 2017;
Arunjaroensuk, Panmekiate, & Pimkhaokham, 2018; Kamankatgan,
Pimkhaokham, & Krisdapong, 2017). CAIS systems were developed
to accurately transfer the digitally planned optimal 3D implant po‐
sition to the surgical site. Several authors reported that implants
placed using CAIS systems were more accurate than those using
conventional methods (Farley et al., 2013; Hoffmann, Westendorff,
Gomez‐Roman, & Reinert, 2005; Kramer, Baethge, Swennen, &
Rosahl, 2005; Ruppin et al., 2008; Somogyi‐Ganss et al., 2015).
In this study, no significant differences were found in terms of
implant deviation between the two groups. Both static and dynamic
CAIS systems provided accurate placement of single implant in rela‐
tion to the planed position, with mean platform and apex deviations
less than 1.05 mm and 1.29 mm, respectively, and mean angular
deviation less than 3.06 degrees. Moreover, in term of precision of
implant placement, both methods yielded close precision as repre‐
sented by 95% CIs (Table 3). The deviation achieved in both groups
was smaller than the results reported by past in vitro studies by
Ruppin et al. (2008) (Ruppin et al., 2008) which compared preop‐
erative and postoperative CT scans in partially and fully edentulous
human cadaver mandibles using static and dynamic CAIS systems.
They also reported no significant difference between CAIS systems
with the mean platform deviation of less than 1.5 mm and mean
angular deviation of less than 8.1 degrees. Somogyi‐Gnass et al.
(2015) (Somogyi‐Ganss et al., 2015) compared the deviation of im‐
plant bed preparations between static and dynamic CAIS systems in
partially edentulous maxilla and mandible models, also reporting no
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significant differences, while mean platform and apex deviation was
less than 1.91 mm and 1.14 mm, respectively, and mean angular de‐
viation was less than 4.24 degrees for both systems. However, these
in vitro studies were performed in cadavers and study models, which
provided better access, better visual control, no patient movement,
and absent of soft tissue, saliva, and blood that can influence surgical
placement conditions and accuracy. In that sense, it is not surpris‐
ing to expect higher accuracy reported in in vitro studies, something
that can also be reflected in as shown in several systematic reviews.
The present results are consistent with several systematic reviews
and meta‐analyses which reported the accuracy of CAIS systems
in clinical studies, where the deviation was less than 1.22 mm and
1.45 mm at platform and apex, respectively, and less than 4.06 de‐
grees for angular deviation (Bover‐Ramos, Vina‐Almunia, Cervera‐
Ballester, Penarrocha‐Diago, & Garcia‐Mira, 2018; Jung et al., 2009;
Sicilia, Botticelli, & Working, 2012; Tahmaseb, Wismeijer, Coucke, &
Derksen, 2014; Tahmaseb, Wu, Wismeijer, Coucke, & Evans, 2018;
Van Assche et al., 2012). Nevertheless, such systematic reviews con‐
tain a diversity of study designs, surgical protocols, and operators
while utilizing different CAIS and implant systems. Such lack of ho‐
mogeneity observed in systematic reviews (I2 = 71.6%–99%) could
limit the ability to extrapolate results. Consequently, one strength
of this study is the strict randomization protocol (thus eliminating
any risk for selection bias) and the execution of all surgeries by one
experienced surgeon (thus eliminating any operator effect).
When analyzing the vector of the deviation at implant platform
and apex for both groups, no significant difference in bucco‐lingual
and apico‐coronal direction was found. Interestingly, the median
value of implants which deviated to mesial direction in static CAIS
group was significantly different to that of the dynamic CAIS group
when measured at the implant platform. This might be due by poorer
visibility and the presence of an operator's “blind spot” on the me‐
sial side of the edentulous area particularly in posterior region. As
most of the implants in this study were placed in posterior edentu‐
lous area and implant placement using dynamic CAIS system relies in
visual control, this “blind spot” might have resulted in the difference
observed, hindering sight at the distal of the mesial tooth. Moreover,
the rotational movement of human hand and wrist might also affect
the mesial deviation in dynamic CAIS group compared with static
CAIS group where positioning of the drills is guided. However, this
mesial deviation in dynamic CAIS group was smaller comparing to
the respective deviation reported in studies with conventional im‐
plant placement (Block et al., 2017; Farley et al., 2013; Somogyi‐
Ganss et al., 2015).
Implant deviation is the sum of possible errors from image acqui‐
sition, image data processing, surgical template manufacturing, type
of surgical template support, level of guidance in osteotomy and im‐
plant placement procedure, registration procedure, and human error
(Mora, Chenin, & Arce, 2014; Widmann & Bale, 2006). The resolution
of the digital image volume affects the accuracy of the virtual plan‐
ning procedure followed by the deviation of final implant position
transferred from the virtual plan. The resolution of data depends on
the voxel size, the smaller the voxel size, the higher the resolution,
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and the measurement accuracy (Widmann & Bale, 2006). CBCT was
shown to be a useful tool in preoperative evaluation for dental im‐
plant placement because of its higher resolution, lower radiation ex‐
posure, and shorter scanning times compared to conventional CT.
Kobayashi, Shimoda, Nakagawa, and Yamamoto (2004) (Kobayashi
et al., 2004) compared the accuracy of distance measurement in
mandible between using spiral CT and CBCT and reported that
mean measurement error of spiral CT (0.36 ± 0.24 mm) was signifi‐
cantly higher than CBCT (0.22 ± 0.15 mm). In our study, all patients
received CBCT scans using the same machine operated by one ex‐
perienced radiologist with the voxel size of 0.25 × 0.25 × 0.25 mm.
These settings provided resolution comparable to this of previous
studies (Block et al., 2017; Farley et al., 2013; Hoffmann et al., 2005;
Ruppin et al., 2008) and the image data processing followed the
orientation and cross‐sectional principles described by Mora et al.
(2014) (Mora et al., 2014), so that both image acquisition and pro‐
cessing could be reliable.
The position of the drills and implant placement in the static CAIS
group were controlled by teeth‐supported surgical guide, which
provides better accuracy for implant placement compared to mu‐
cosa‐ and bone‐supported guides. Still deviation of the drills and the
implant can also occurred (Behneke et al., 2012; Ersoy, Turkyilmaz,
Ozan, & McGlumphy, 2008; Ozan, Turkyilmaz, Ersoy, McGlumphy, &
Rosenstiel, 2009; Tahmaseb et al., 2014). The most important source
of error in static CAIS system appears to be the intrinsic error such
as misfit of the guide or the metal sleeve and drills. Other sources of
error can be are procedure‐related, such as positioning error of the
template and interference of the opposing dentition hindering the
correct positioning of the drills and implant (Cassetta, Di Mambro,
Giansanti, Stefanelli, & Cavallini, 2013). In this study, the surgical
templates were fabricated by stereolithographic rapid prototyping
method using photosensitive liquid acrylic, which has been used in
previous studies and is reported to provide accurate transfer of the
implant position (Ersoy et al., 2008; Farley et al., 2013; Ozan et al.,
2009; Ruppin et al., 2008; Somogyi‐Ganss et al., 2015). The stabil‐
ity and intimate fit of the template was also confirmed through the
observation window on the template before the surgery was per‐
formed. All patients had proper mouth opening (at least 40 mm of
inter‐incisal distance) to perform implant placement with the surgical
template in place. Therefore, it is anticipated that errors from surgi‐
cal template manufacturing and application were kept to a minimum.
Several factors can influence the accuracy of dynamic CAIS
system. Error from tracking system has been reported as target
registration error (TRE), which refers to the deviation between the
corresponding points on CT image and surgical site other than the
fiducial points after registration (Widmann & Bale, 2006). In this
study, an occlusal stent with fiducial markers was used as the regis‐
tration device which is a noninvasive technique, provides acceptable
accuracy, and is easy to perform particularly in patients who have
sufficient teeth to support the surgical guide. Luebbers et al. (2008)
(Luebbers et al., 2008) reported that when using an occlusal stent as
the registration method, the minimum TRE measured closed to max‐
illary teeth was 0.4 mm, while the TRE increased with the distance
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512       KAEWSIRI et al.
from the plane of fiducial markers on maxillary teeth. The result is
consistent with Casap, Wexler, and Eliashar (2008) (Casap et al.,
2008) that reported the TRE of less than 0.5 mm when using teeth‐
supported fiducial markers as the registration method for lower jaw
surgery. In our study, the registration procedure was performed by
one clinician who had conducted the reliability test for the accuracy
of registration in study models prior to surgeries. The intraclass cor‐
relations coefficient was 0.84, which indicated good reliability, sug‐
gesting the procedure to have been not affected by human error.
Human error also has an effect on the accuracy of implant place‐
ment especially in dynamic CAIS system. In this system, the position
and angulation of the drills and implant were controlled by surgeon's
hand without any mechanical guidance instruments. The procedure
is consequently susceptible to hand tremor and perception inaccu‐
racy, which can cause deviation of about 0.25 mm and 0.5 degrees
(Widmann & Bale, 2006). The success of transferring the virtual
implant position to the surgical site relies on the eye‐hand coordi‐
nation skill of the surgeon to interpret the data on navigation mon‐
itor together with handling of the drill and implant during surgery
(Somogyi‐Ganss et al., 2015; Widmann & Bale, 2006). Operating dy‐
namic CAIS system with proficiency requires also a significant learn‐
ing period by the surgeon. Block et al. (2017) reported that implant
placement using dynamic CAIS system performed by experienced
surgeon was more accurate than inexperienced surgeon  (Block et
al., 2017). In contrast, Cassetta and Bellardini (2017) demonstrated
that the accuracy of implant placement in full edentulous patient
using static CAIS system was not significantly different between
experienced and inexperienced surgeons. Only positioning error
of mucosa‐supported template was higher in the inexperienced
group (Cassetta & Bellardini, 2017). Rungcharassaeng, Caruso, Kan,
Schutyser, and Boumans (2015) also reported that the accuracy of
implant placement using tooth‐supported static CAIS system was
not significant difference between experienced and inexperienced
operators (Rungcharassaeng et al., 2015). In our study, only one sur‐
geon who had placed more than 500 implants using conventional
method and more than 50 implants using each static and dynamic
CAIS systems performed all surgeries, so implant placement in both
groups could be as comparable as possible.
Implant bed preparation in areas with asymmetric bone density
also could lead to deviation of the drill toward the pathway of least
resistance (Block et al., 2017). In the present study, the maximum
implant deviation was found in the dynamic CAIS group 2.04 mm at
the platform and 2.31 mm at the apex, respectively. In this particular
case, the implant was placed into the area of a mandibular molar,
extracted 3 months before the surgery. Asymmetric bone density
due to the remaining bone septum was observed and the implant
deviated mesially from the planned optimal position. In such cases of
dense interradicular septum post extraction and when dynamic CAIS
is to be used, it might be advisable to perform the implant placement
more than 3 months after the extraction, aiming to obtain proper
healing and symmetric bone density.
Advantages of dynamic CAIS over static CAIS include the ability
to directly observe and irrigate the surgical site without interference
of the surgical guide. The surgery can be performed using conven‐
tional instrument and drills of several implant systems included in
the database, whereas static CAIS system requires specific drilling
system, guided instruments, and for some systems also specific
implant fixture, which incurs costs and time as well as laboratory
services. On the other hand, static CAIS system typically requires
less surgical time compared with dynamic CAIS, as the surgical tem‐
plate provides mechanical guidance of the drill and implant position
without the need for additional time for adjustments. Furthermore,
dynamic CAIS requires clear line of sight between tracking cameras
and sensors, a registration prior to surgery which can take from 2 to
5 min, and relatively high purchase cost of navigation machine is also
an important factor to be considered.
5 | CO N C LU S I O N
Implant placement in single tooth space is a straightforward clini‐
cal procedure in implant dentistry, especially in the nonesthetic
zone and when not involving bone augmentation. Within the limi‐
tations of this study, implant placement in single tooth space using
dynamic CAIS system is shown to be as accurate as using static
CAIS system. The conclusions only reflect the results in this in‐
vestigation on specific CAIS systems and might not apply to all
available systems. Further studies will be required to compare the
accuracy of such systems in more challenging anatomic conditions,
such as with multiple implants in partially and fully edentulous pa‐
tient. Comparison of cost‐benefits, cost‐effectiveness, influence
of operator experience, and learning curve between static and dy‐
namic CAIS systems should also be performed.
AC K N OW L E D G E M E N T
This research was supported by the 90th Anniversary of
Chulalongkorn University Rachadapisek Sompote Fund.
ORCID
Keskanya Subbalekha  https://orcid.org/0000-0002-1570-2289
Nikos Mattheos  https://orcid.org/0000-0001-7358-7496
Atiphan Pimkhaokham  https://orcid.org/0000-0002-0170-243X
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Widmann, G., & Bale, R. J. (2006). Accuracy in computer‐aided implant

surgery–a review. International Journal of Oral and Maxillofacial How to cite this article: Kaewsiri D, Panmekiate S,
Implants, 21(2), 305–313. Subbalekha K, Mattheos N, Pimkhaokham A. The accuracy of
static vs. dynamic computer‐assisted implant surgery in single

S U P P O R T I N G I N FO R M AT I O N tooth space: A randomized controlled trial. Clin Oral Impl Res.

2019;30:505–514. https​://doi.org/10.1111/clr.13435​
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